Dor Lombar Baixa

Question 1

Como é o suprimento sanguineo e a nutrição do disco intervertebral?

Answer 1

At birth, the disc has some direct blood supply con­tained within the cartilaginous endplates and the anulus. These vessels recede in the first years of life, and by adulthood there is no appreciable blood supply to the disc. The cells within the disc are sustained by difusion of nutrients into the disc through the porous central concavity of the vertebral endplate.

Question 2

Qual é caracteristica encontrada nos discos herniados?

Answer 2

Herniated discs have a greater number of senescent cells than nonherniated discs and have higher con­centrations of matrix metalloproteinases.

Question 3

Quais são as características das células do ânulo fibroso e do núcleo pulposo dos discos intervertebrais?

Answer 3

The anulus cells are more elongated and appear more like fibroblasts, whereas nucleus cells are oval and resemble chondrocytes. The anulus cells produce predominantly type I collagen, whereas nucleus cells synthesize type II collagen.

Question 4

Qual é o tempo de turnover dos glicosaminoglicanos nos discos intervertebrais?

Answer 4

The gly­cosaminoglycan turnover in the disc is quite slow, requiring 500 days.

Question 5

Como estão organizadas as raízes nervosas na medula espinhal? Como se organizam as raízes motoras e sensitivas?

Answer 5

The orientation of the nerve roots in the dural sac and at the conus medullaris follows a highly organized pattern, with the most cephalad roots lying lateral and the most caudad lying centrally. The motor roots are ventral to the sensory roots at all levels.

Question 6

Como é a padronização da nomenclatura das raízes emergentes na coluna vertebral?

Answer 6

Accepted nomenclature allows each cervical root to exit cephalad to the pedicle of the vertebra for which it is named (e.g., the C6 nerve root exits above or cephalad to the C6 pedicle). This relationship changes in the thoracic spine because the C8 root exits between the C7 and T1 pedicles, requiring the T1 root to exit caudal or below the pedicle for which it is named. This relationship is maintained throughout the remaining more caudal segments.

Question 7

Como é organizada a inervação das estruturas vertebrais dos ramos distais ao gânglio da raíz dorsal?

Answer 7

Distal to the ganglion, three distinct branches arise; the most prominent and important is the ventral ramus, which supplies all structures ventral to the neural canal. The second branch, the sinu­vertebral nerve, is a small filamen­tous nerve that originates from the ventral ramus and progresses medially over the posterior aspect of the disc and vertebral bodies, innervating these structures and the poste­rior longitudinal ligament. The third branch is the dorsal ramus. This branch courses dorsally, piercing the intertrans­verse ligament near the pars interarticularis. Three branches from the dorsal ramus innervate the structures dorsal to the neural canal. The lateral and intermediate branches provide innervation to the posterior musculature and skin. The medial branch separates into three branches to innervate the facet joint at that level and the adjacent levels above and below.

Question 8

Como é dividido o processo degenerativo da coluna vertebral?

Answer 8

The degenerative process has been divided into three separate stages with relatively distinct findings. The first stage is dysfunction, which is seen in individuals 15 to 45 years old. It is characterized by circumferential and radial tears in the disc anulus and localized synovitis of the facet joints. The next stage is instability. This stage, found in 35­ to 70­ year-­old patients, is characterized by internal disruption of the disc, progressive disc resorption, degeneration of the facet joints with capsular laxity, subluxation, and joint erosion. The final stage, present in patients older than 60 years, is stabilization. In this stage, the progressive development of hypertrophic bone around the disc and facet joints leads to segmental stifening or frank ankylosis.

Question 9

De acordo com os estágios do processo degenerativo da coluna vertebral, em qual deles se encaixam as hérnias de disco e a estenose do canal vertebral?

Answer 9

Disc herniation in this scheme is con­sidered a complication of disc degeneration in the dysfunc­tion and instability stages. Spinal stenosis from degenerative arthritis in this scheme is a complication of bony overgrowth compromising neural tissue in the late instability and early stabilization stages.

Question 10

Como o tratamento cirúrgico pode melhorar as queixas de dores lombares nos pacientes?

Answer 10

Operative treatment can benefit a patient if it corrects a deformity, corrects instability, relieves neural compression, or treats a combination of these problems.

Question 11

Qual a porcentagem de pacientes apresenta hérnias de disco assintomático nos estudos de imagem?

Answer 11

An overdepen­dence on the diagnosis of disc herniation can occur with early use of these diagnostic studies, which show disc herniations in 20% to 36% of normal volunteers.

Question 12

Quais são as indicações para solicitar radiografias para pacientes com dores lombares?

Answer 12

Age > 50 years
Significant trauma
Neuromuscular deficits
Unexplained weight loss (10 lb in 6 months)
Suspicion of ankylosing spondylitis
Drug or alcohol abuse
History of cancer
Use of corticosteroids
Temperature ≥ 37.8°C (≥100°F)
Recent visit (≤1 month) for same problem and no improvement
Patient seeking compensation for back pain

Question 13

Como é a correlação clínica e de imagem nos pacientes com dores lombares?

Answer 13

Severe nerve compression shown by MRI or CT correlates with symptoms of distal leg pain; however, mild­to­moderate nerve compression, disc degeneration or bulging, and central stenosis do not correlate significantly with specific pain patterns.

Question 14

Como é realizada a incidência radiográfica de Ferguson e qual a sua utilidade?

Answer 14

The Ferguson view (20 ­degree caudocephalic anteroposterior radiograph) has been shown to be of value in the diagnosis of the “far out syndrome,” that is, fifth root compression produced by a large trans­verse process of the fifth lumbar vertebra against the ala of the sacrum.

Question 15

Quais são as indicações primárias para realização de mielografia?

Answer 15

The primary indications for myelogra­phy are suspicion of an intraspinal lesion, patients with spinal instrumentation, or questionable diagnosis resulting from conflicting clinical indings and other studies.

Question 16

Quais são as vantagens e desvantagens do uso de contrastes hidrosolúveis para a realização de mielografia?

Answer 16

Water­soluble contrast media are now the standard agents for myelography. Their advantages include absorption by the body, enhanced definition of structures, tolerance, and the ability to vary the dosage for diferent contrasts. The complications of these agents include nausea, vomiting, confusion, and sei­zures.

Question 17

A injeção epidural de corticóide apresenta melhores resultados quando aplicada de qual forma?

Answer 17

A retrospective study comparing interlaminar to transforaminal epidural injections for symp­tomatic lumbar intervertebral disc herniations found that transforaminal injections resulted in better short­term pain improvement and fewer long­term operative interventions.

Question 18

Quais complicações podem ocorrer com a injeção epidural de corticóide?

Answer 18

Few serious complications occur in patients receiving epidural corticosteroid injections; however, epidural abscess, epidural hematoma, durocutaneous fistula, and Cushing syn­drome have been reported as individual case reports. The most adverse immediate reaction during an epidural injec­tion is a vasovagal reaction.

Question 19

Quais são as contra-indicações para a realização de injeção epidural de corticóides?

Answer 19

Epidural corticosteroid injec­tions are contraindicated in the presence of infection at the injection site, systemic infection, bleeding diathesis, uncon­trolled diabetes mellitus, and congestive heart failure.

Question 20

Qual a taxa de falha na injeção epidural de corticóide sem radioscopia?

Answer 20

Even in experienced hands, needle misplacement occurs in 40% of caudal and 30% of lumbar epidural injections when done without fluoroscopic guidance.

Question 21

Quais são as evidências para a injeção epidural de corticóides em pacientes com dores lombares?

Answer 21

When nerve root injury is associated with a disc herniation or lateral bony stenosis, most patients who received substantial relief of leg pain from a well­placed transforaminal injection, even if temporary, benefit from surgery for the radicular pain. Patients who do not respond and who have had radicular pain for at least 12 months are unlikely to benefit from surgery. Patients with back and leg pain of an acute nature (

Question 22

Qual é o método gold standard para avaliar a participação da faceta articular como causadora da dor lombar?

Answer 22

Fluoroscopically guided facet joint injections are commonly considered the “gold standard” for isolating or excluding the facet joint as a source of spine or extremity pain.

Question 23

Quando suspeitar que a dor lombar é originária da articulação sacroiliaca?

Answer 23

Sacroiliac joint dysfunction should be con­sidered, however, if an injury was caused by a direct fall on the buttocks, a rear-­end motor vehicle accident with the ipsi­lateral foot on the brake at the moment of impact, a broadside motor vehicle accident with a blow to the lateral aspect of the pelvic ring, or a fall in a hole with one leg in the hole and the other extended outside. Lumbar rotation and axial loading that can occur during ballet or ice skating is another common mechanism of injury.

Question 24

Qual a região mais associada a dor originária na articulação sacroiliaca?

Answer 24

In studies of asymptomatic subjects, the most constant referral zone was localized to a 3 × 10­cm area just inferior to the ipsilateral posterior superior iliac spine; however, pain may be referred to the buttocks, groin, posterior thigh, calf, and foot.

Question 25

Qual a aplicação mais importante da discografia?

Answer 25

The most important aspect of discography is provocative testing for concordant pain (pain that corresponds to a patient’s usual pain) to provide information regarding the clinical significance of the disc abnormality.

Question 26

Quais são as indicações de discografia lombar?

Answer 26

Indications for lumbar discography include operative planning of spinal fusion, testing of the structural integrity of an adjacent disc to a known abnormality such as spon­dylolisthesis or fusion, identifying a painful disc among multiple degenerative discs, ruling out secondary internal disc disruption or suspected lateral or recurrent disc hernia­tion, and determining the primary symptom-­producing level when chemonucleolysis is being considered.

Question 27

Quais são as contra-indicações para a realização de discografia?

Answer 27

Compression of the spinal cord, stenosis of the roots, bleeding disorders, allergy to the injectable material, and active infection are contraindications to diagnostic disc­ography procedures.

Question 28

Quais são os riscos das discografias?

Answer 28

Although the risk of complications from discography is low, potential problems include discitis, nerve root injury, subarachnoid puncture, chemical menin­gitis, bleeding, and allergic reactions. In addition, in the cervical region, retropharyngeal and epidural abscess can occur. Pneumothorax is a risk in the cervical and thoracic regions.

Question 29

Como é a epidemiologia das hérnias de disco cervicais?

Answer 29

Cervical disc disease is slightly more common in men. Factors associated with the injury are frequent heavy lifting on the job, cigarette smoking, and fre­quent diving from a board. Patients with cervical disc disease also are likely to have lumbar disc disease.

Question 30

Onde ocorrem as mudanças hipertróficas na coluna cervical em relação a fisiopatologia da doença do disco?

Answer 30

In contrast to those in the lumbar spine, these hypertrophic changes are predominantly at the unco­ vertebral joint (uncinate process).

Question 31

Nos estágios finais, quais são os achados nas colunas cervical e lombar dos processos degenerativos?

Answer 31

As in lumbar disease, progressive stifening of the cervical spine and loss of motion are the usual result in the end stages.

Question 32

Quais são os tratamentos cirurgicos mais utilizados para hérnias de disco cervicais?

Answer 32

Currently, anterior cervical discectomy with fusion is the procedure of choice when the disc is removed anteriorly to avoid disc space collapse, prevent painful and abnormal cervical motion, and speed interverte­bral fusion. Foraminotomy is the procedure of choice when the disc fragment can be removed posteriorly.

Question 33

Quais são as queixas mais comuns de pacientes com hérnia de disco cervical em relação a coluna vertebral?

Answer 33

Complaints of neck pain, medial scapular pain, and shoulder pain are probably related to primary pain around the disc and spine.

Question 34

Quais são os sintomas de compressão radicular esperados em pacientes com discopatia cervical?

Answer 34

Symptoms of root compression usually are associated with pain radiating into the arm or chest with numbness in the fingers and motor weakness. Cervical disc disease also can mimic cardiac disease with chest and arm pain. Usually the radicular symptoms are intermittent and combined with more frequent neck and shoulder pain.

Question 35

Quais os sinais de mielopatia esperados em um paciente com discopatia cervical?

Answer 35

The signs of midline cervical spinal cord compression (myelopathy) are unique and varied. The pain is poorly local­ized and aching and may be only a minor complaint. Occa­sional sharp pain or generalized tingling may be described with neck extension. This is similar to the Lhermitte sign in multiple sclerosis. The pain can be in the shoulder and pelvic girdles; it is occasionally associated with a generalized feeling of weakness in the lower extremities and a feeling of instability.

Question 36

Quais os achados esperados na compressão da raíz de C5?

Answer 36

Sensory Deficit = Upper lateral arm and elbow Motor Weakness = Deltoid Biceps (variable) Reflex Change = Biceps (variable)

Question 37

Quais os achados esperados na compressão da raíz de C6?

Answer 37

Sensory Deficit = Lateral forearm, thumb, and index finger | Motor Weakness = Biceps, Extensor carpi radialis longus and brevis Reflex Change = Biceps, Brachioradialis

Question 38

Quais os achados esperados na compressão da raíz de C7?

Answer 38

Sensory Deficit = Middle finger (variable because of overlap) Motor Weakness = Triceps, Wrist flexors (flexor carpi radialis), Finger extensors (variable) Reflex Change = Triceps

Question 39

Quais os achados esperados na compressão da raíz de C8?

Answer 39

Sensory Deficit = Ring finger, little finger, and ulnar border of palm Motor Weakness = Interossei, Finger flexors (variable), Flexor carpi ulnaris (variable) Reflex Change = None

Question 40

Quais os achados esperados na compressão da raíz de T1?

Answer 40

Sensory Deficit = Medial aspect of elbow Motor Weakness = Interossei Relex Change = None

Question 41

Como realizar o shoulder abduction relief test?

Answer 41

The shoulder abduction relief sign can be helpful in diagnosing cervical root compression syndromes. The test consists of shoulder abduction and elbow flexion with placement of the hand on the top of the head. This maneuver should relieve the arm pain caused by radicular compression. If this position is allowed to persist for 1 or 2 minutes and pain is increased, more distal compressive neuropathies such as a tardy ulnar nerve syndrome (cubital tunnel syndrome) or primary shoulder pathological conditions often are the cause.

Question 42

Como é realizado o teste da distração?

Answer 42

The distraction test, which involves the examiner placing the hands on the occiput and jaw and distracting the cervical spine in the neutral position, can relieve root com­ pression pain but also can increase pain caused by ligamen­ tous injury. Neck extension and flexion with or without traction can be helpful in selecting conservative therapies.

Question 43

Quais são as possiveis causas das dores cervicais em pacientes que apresentam alivio dos sintomas com a extensão do pescoço? E aqueles com alívio com a flexão do pescoço?

Answer 43

Patients relieved of pain with the neck extended, with or without traction, usually have hyperextension syndromes with ligamentous injury posteriorly, whereas patients relieved of pain with distraction and neck flexion are more likely to have nerve root compression caused by a soft ruptured disc or more likely hypertrophic spurs in the neural foramina.

Question 44

Quais são os sinais de compressão central do canal medular na região cervical?

Answer 44

If the lesion is high in the cervical region, paresthesias, weakness, atrophy, and occasionally fascicula­tions may occur in the hands. A Hofman sign (upper cervical spinal cord) or the inverted radial reflex (typically indicating C5­-6 pathology) also may be present. Most commonly, however, the first and most prominent symptoms are those of involvement of the corticospinal tract; less commonly, the posterior columns are afected. The primary signs are sustained clonus, hyperactive relexes, and the Babinski reflex. Less significant findings are varying degrees of spasticity, weakness in the legs, and impairment of proprioception. Equilibrium may be grossly disturbed, but sense of pain and temperature sense rarely are lost and usually are of little localizing value.

Question 45

Em relação aos diagnosticos diferenciais de discopatia cervical, quais são os fatores extrínsecos e os fatores intrínsecos?

Answer 45

``` Extrínsecos = tumors of the chest; nerve com­pression syndromes distal to the spine; degenerative pro­cesses, such as shoulder and upper extremity arthritis; temporomandibular joint syndrome; and lesions around the shoulder, such as acute and chronic rotator cuf tears and impingement syndromes. Intrínsecos = cervical disc degeneration with con­comitant disc herniation or later development of hypertro­phic arthritis. Congenital factors, such as spinal stenosis in the cervical region, also may produce symptoms. Primary and secondary tumors of the cervical spine and fractures of the cervical vertebrae also should be considered as intrinsic lesions. ```

Question 46

Como Odom classificou as discopatias cervicais?

Answer 46

Odom et al. categorized cervical disc disease into four groups: (1) unilateral soft disc protrusion with nerve root compression; (2) foraminal spur, or hard disc, with nerve root compression; (3) medial soft disc protrusion with spinal cord compression; and (4) transverse ridge or cervical spon­dylosis with spinal cord compression. Soft disc herniations usually afect one level, whereas hard disc herniations can afect multiple levels. Central lesions usually result in cord compression symptoms, and lateral lesions usually result in radicular symptoms.

Question 47

Segundo Odom, qual o local mais acometido por discopatia cervical?

Answer 47

Most of the soft disc herniations in the series of Odom et al. occurred at the C6 interspace (70%) and C5 interspace (24%). Only six occurred at the C7 interspace. Foraminal spurs also were found predominantly at the C6 interspace (48%).

Question 48

O que ocorre com o disco herniado ao longo do tempo?

Answer 48

Reasonably good evidence shows that acute disc herniations decrease in size over time in the cervical region.

Question 49

Qual o foco do tratamento conservador para discopatia cervical? Como realizá-lo?

Answer 49

The cervical spine is vulnerable to mus­cular tension forces, postural fatigue, and excessive motion. Most nonoperative treatments focus on one or more of these factors. The best primary treatment is short periods of rest, massage, ice, and antiinflammatory agents with active mobi­lization as soon as possible. The position of the neck for comfort is essential for relief of pain. The position of greatest relief may suggest the ofending pathological process or mechanism of injury. Patients with hyperlexion injuries usually are more comfortable with the neck in extension over a small roll under the neck. No specific position indicates lateral disc herniation, although most patients tolerate the neutral position best. Patients with spondylosis (hard disc) are most comfortable with the neck in flexion.

Question 50

Quais são as indicações cirurgicas para discopatia cervical?

Answer 50

he primary indications for operative treatment of cervical disc disease are (1) failure of nonoperative pain management; (2) increasing and significant neurological deficit; and (3) cervical myelopathy, which predictably progresses, based on natural history studies.

Question 51

Quando indicar VA ou VP na discopatia cervical?

Answer 51

The approach chosen should be determined by the location and type of lesion. Soft lateral discs are easily removed with the posterior approach, whereas soft central or hard discs (central or lateral) probably are best treated with an anterior approach.

Question 52

Quais são as vantagens das tecnicas minimamente invasivas para tratamento cirurgico da discopatia cervical?

Answer 52

Cited advantages of these “minimally invasive” techniques include shorter operative time, fewer operative risks, less blood loss, less postoperative pain, and earlier return to activity.

Question 53

Quais são as indicações para cirurgia minimamente invasiva nas discopatias cervicais?

Answer 53

Indications for minimally invasive posterior cervical procedures include radiculopathy caused by lateral disc herniation or foraminal stenosis, persistent or recurrent nerve root symptoms after anterior cervical discectomy, and cervical disc disease in patients for whom anterior approaches are contraindicated (e.g., those with anterior neck infection, tracheostomy, prior irradiation, previous radical neck surgery or neoplasm).

Question 54

Quais são as contraindicações para técnica minimamente invasiva para as discopatias cervicais?

Answer 54

Contraindications are much the same as those for open treatment and include pure axial neck pain without neurologic symptoms, gross cervical instability, symptomatic central disc herniation, and kyphotic deformity that would make posterior decompression inefective.

Question 55

Como é a técnica anterior de Cloward para tratamento de discopatias cervicais?

Answer 55

The Cloward technique involves making a round hole centered at the disc space. A slightly larger, round iliac crest plug is inserted into the disc space hole.

Question 56

Como é a técnica anterior de Smith-Robinson para discopatia cervical?

Answer 56

The Smith­-Robinson technique involves inserting a tri­-cortical strut of iliac crest into the disc space after removing the disc and cartilaginous endplate. The graft is inserted with the cancellous side facing the cord (posterior).

Question 57

Como é a técnica anterior de Bailey-­Badgley para tratamento de doenças cervicais?

Answer 57

The Bailey-­Badgley tech­nique involves the creation of a slot in the superior and infe­rior vertebral bodies. This technique is most applicable to reconstruction when one or more vertebral bodies are excised for tumor, stenosis, or other extensive pathological conditions.

Question 58

Qual das técnicas anteriores apresenta a melhor estabilidade anterior para o tratamento de discopatias cervicais?

Answer 58

Biomechanically, the Smith-­Robinson technique provides the greatest stability and least risk of extrusion compared with the Cloward and Bailey­-Badgley types of fusions.

Question 59

As vias de acesso anterior devem ser realizadas de qual lado? Por quê?

Answer 59

Exposure from the left is less convenient for a right­ handed surgeon but may decrease the risk of recurrent laryngeal nerve injury. The course of the nerve on the right is not as consistent.

Question 60

Qual o argumento principal favorável a artroplastia do disco cervical?

Answer 60

The primary argument favoring these devices is that, by avoiding anterior fusion, adjacent segment degeneration can be minimized, reducing the need for reoperation. The indications for cervical disc arthroplasty appear to be similar to those for ACDF.

Question 61

Qual o local de menor prevalência de discopatia na coluna vertebral?

Answer 61

The thoracic spine is the least common location for disc pathology.

Question 62

Qual a faixa etária mais acometida por discopatia torácica?

Answer 62

The most common age at onset is between the fourth and sixth decades.

Question 63

Quais são as indicações para tratamento cirurgico de discopatia torácica?

Answer 63

Operative treatment of thoracic disc her­niations is indicated in rare patients with acute disc hernia­tion with myelopathic findings attributable to the lesion, especially progressive neurological symptoms.

Question 64

Quais são os diagnósticos diferenciais de discopatia torácica?

Answer 64

he diferential diagnosis for the symptoms of thoracic disc her­niations is fairly extensive and includes nonspinal causes occurring with the cardiopulmonary, gastrointestinal, and musculoskeletal systems. Spinal causes of similar symptoms can occur with infectious, neoplastic, degenerative, and meta­bolic problems within the spinal column and the spinal cord.

Question 65

Quais são as duas populações descritas com discopatia torácica?

Answer 65

The smaller group of patients is younger and has a relatively short history of symptoms, oten with a history of trauma. The larger group of patients has a longer history, often more than 6 to 12 months of symptoms, which result from chronic spinal cord or root compression.

Question 66

Quais são os padrões de dor apresentados pelos pacientes com discopatia torácica?

Answer 66

Two patterns of pain are apparent: one is axial, and the other is bandlike radicular pain along the course of the intercostal nerve. The T10 dermatomal level is the most commonly reported distribution, regardless of the level of involvement. This is a band extending around the lower lateral thorax and caudad to the level of the umbi­licus. This radicular pattern is more common with upper thoracic and lateral disc herniations.

Question 67

Discopatias cervicais altas podem se manifestar de qual forma?

Answer 67

High thoracic discs (T2 to T5) can manifest similarly to cervical disc disease with upper arm pain, paresthesias, radiculopathy, and Horner syndrome. Myelopathy also may occur.

Question 68

Por que a RNM pode subestimar a discopatia torácica?

Answer 68

Despite all of these advantages, MRI may underestimate the thoracic disc herniation, which oten is calcified and has low signal intensity on T1­ and T2­ weighted sequences.

Question 69

Quais são os principios de tratamento conservador para discopatia torácica?

Answer 69

The principles of short­term rest, pain relief, anti-inlammatory agents, and progressive directed activity restoration seem most appropriate. These measures generally should be continued at least 6 to 12 weeks if feasible. If neurological deficits progress or manifest as myelopathy, or if pain remains at an intolerable level, surgery should be recommended.

Question 70

Quais são os acessos cirúrgicos possíveis para tratamento da discopatia torácica?

Answer 70

Most more recent studies suggest that lateral rachiotomy (modified costotransversectomy) or an anterior transthoracic approach for discectomy produces considerably better results with no evidence of worsening after the procedure. Video­assisted thoracic surgery (VATS) has been used in several series to remove central thoracic disc herniations successfully without the need for a thoracotomy or fusion.

Question 71

Quando indicar a costotranversectomia na discopatia torácica?

Answer 71

Costotransversectomy is probably best suited for thoracic disc herniations that are predominantly lateral or herniations that are suspected to be extruded or sequestered. Central disc herniations are probably best approached transthoracically. Some surgeons have recommended subsequent fusion after disc removal anteriorly or laterally.

Question 72

Qual a faixa etária predominante nas doenças dos discos intervertebrais?

Answer 72

Intervertebral disc disease and disc herniation are most prominent in otherwise healthy people in the third and fourth decades of life.

Question 73

Quais estruturas anatomicas podem provocar dor lombar e dor na face posterior da coxa?

Answer 73

Back and posterior thigh pain of this type can be elicited from many areas of the spine, including the facet joints, longitudinal ligaments, and periosteum of the verte­bra. Radicular pain usually extends below the knee and follows the dermatome of the involved nerve root.

Question 74

Como é a dor característica da discopatia lombar?

Answer 74

The usual history of lumbar disc herniation is of repeti­tive lower back and buttock pain, relieved by a short period of rest. This pain is suddenly exacerbated, often by a flexion episode, with the appearance of leg pain. The pain from disc herniation usually varies, increasing with activity, especially sitting. The pain can be decreased by rest, especially in the semi-­Fowler position, and can be exacerbated by straining, sneezing, or coughing.

Question 75

Quais são os sintomas da síndrome da cauda equina?

Answer 75

These symptoms include numbness and weakness in both legs, rectal pain, numbness in the perineum, and paralysis of the sphincters. This diagnosis should be the primary consideration in patients who complain of sudden loss of bowel or bladder control. Whenever the diagnosis of cauda equina syndrome is caused by an acute midline hernia­tion, evaluation and treatment should be aggressive.

Question 76

Quais são os achados de exame físico de um paciente com discopatia lombar?

Answer 76

Usually patients with acute pain show evidence of marked paraspinal spasm that is sustained during walking or motion. A scoliosis or a list in the lumbar spine may be present, and in many patients the normal lumbar lordosis is lost. As the acute episode subsides, the degree of spasm diminishes remarkably, and the loss of normal lumbar lordosis may be the only telltale sign. Point tenderness may be present over the spinous process at the level of the disc involved, and pain may extend laterally in some patients.

Question 77

O que é o flip sign?

Answer 77

Occasionally, if leg pain is significant, the patient leans back from an upright sitting position and assumes the tripod posi­tion to relieve the pain. This is referred to as the “flip sign.”

Question 78

Qual o sinal patognomonico de discopatia lombar?

Answer 78

Contralateral leg pain produced by straight-­leg raising should be regarded as pathognomonic of a herniated intervertebral disc.

Question 79

Quais são os sinais de comprometimento da raiz de L4?

Answer 79

Sensory Deficit = Posterolateral thigh, anterior knee, and medial leg Motor Weakness = Quadriceps (variable), Hip adductors (variable) Anterior Tibial Weakness Reflex change = Patellar tendon Anterior tibial tendon (variable)

Question 80

Quais são os sinais de comprometimento da raiz de L5?

Answer 80

Sensory Deficit = Anterolateral leg, dorsum of the foot, and great toe Motor Weakness = Extensor hallucis longus, Gluteus medius, Extensor digitorum longus and brevis Reflex Change = Usually none, Posterior tibial (dificult to elicit)

Question 81

Quais são os sinais de comprometimento da raiz de S1?

Answer 81

Sensory Deficit = Lateral malleolus, lateral foot, heel, and web of fourth and fifth toes Motor Weakness = Peroneus longus and brevis, Gastrocnemius-soleus complex, Gluteus maximus Reflex Change = Achilles tendon (gastrocnemius-soleus complex)

Question 82

Qual o nível mais acometido pela discopatia lombar?

Answer 82

More than 95% of the ruptures of the lumbar interver­tebral discs occur at L4 or L5. Ruptures at higher levels in many patients are not associated with a positive straight­leg raising test. In these instances, a positive femoral stretch test can be helpful.

Question 83

Como realizar o teste de estiramento do nervo femoral?

Answer 83

This test is done by placing the patient prone and acutely flexing the knee, while placing the hand in the popliteal fossa. When this procedure results in anterior thigh pain, the result is positive, and a high lesion should be sus­pected. In addition, these lesions may occur with a more difuse neurological complaint without significant localizing neurological signs.

Question 84

Como é o tratamento conservador para pacientes com discopatia lombar?

Answer 84

The simplest treatment for acute back pain is rest; gener­ally 2 days of bed rest are better than a longer period. Biome­chanical studies indicate that lying in a semi-­Fowler position (i.e., on the side with the hips and knees flexed) with a pillow between the legs should relieve most pressure on the disc and nerve roots. Muscle spasm can be controlled by the applica­tion of ice, preferably with a massage over the muscles in spasm. Pain relief and anti-inflammatory efect can be achieved with nonsteroidal anti-inflammatory drugs (NSAIDs). Most acute exacerbations of back pain respond quickly to this therapy. As the pain diminishes, the patient should be encour­ aged to begin isometric abdominal and lower extremity exer­ cises. Walking within the limits of comfort also is encouraged. Sitting, especially riding in a car, is discouraged. Continua­ tion of ordinary activities within the limits permitted by pain has been shown to lead to a quicker recovery. Patients with acute back and thigh pain eased by passive extension of the spine in the prone position can benefit from extension exercises rather than flexion exercises. Improvement in symptoms with exten­sion indicates a good prognosis with conservative care.

Question 85

Qual o papel dos narcóticos e relaxantes musculares no tratamento das dores lombares discogênicas?

Answer 85

The current trend seems to be moving away from the use of strong narcotics and muscle relaxants in the outpatient treat­ment of these syndromes.

Question 86

Qual é o paciente ideal para o tratamento cirurgico da discopatia lombar?

Answer 86

The optimal patient is one with predomi­nant (if not only) unilateral leg pain extending below the knee that has been present for at least 6 weeks. The pain should have been decreased by rest, anti-inflammatory medication, or even epidural steroids but should have returned to the initial levels after a minimum of 6 to 8 weeks of conservative care.

Question 87

Quando a facetectomia está indicada nas cirurgias lombares?

Answer 87

Facetectomy usually is reserved for forami­nal stenosis or severe lateral recess stenosis. If more than one facet is removed, a fusion should be considered in addition.

Question 88

Qual é a anomalia de raíz nervosa lombar mais comum?

Answer 88

Conjoined nerve roots are the most common type of anomaly. Various anatomical studies show some type of con­ joined root in 14% to 17% of cadavers.

Question 89

Como são classificadas as anomalias de raízes lombares combinadas?

Answer 89

There are three classes, the first two of which are subdivided. Type 1 occurs when two roots exit the dura with one common sheath. With type 1A anomalies, the cephalad root departs the conjoined stalk at an acute angle to exit below the appro­priate pedicle, and the caudal root travels within the canal to exit also below the appropriate pedicle. If the cephalad root exits at 90 degrees from the conjoined portion, this is a type 1B anomaly. Type 2 anomalies occur when two roots exit through a single foramen. Type 2A anomalies have one vacant foramen; type 2B anomalies have a portion of one of the roots exiting via the other foramen, which may be cephalad to the foramen occupied by the two nerve roots. Type 3 anomalies occur when there is an anastomosing branch between two adjacent nerve roots. This branch crosses the disc space and can easily be injured during discectomy.

Question 90

Qual nível mais comum de localização de raízes lombares combinadas?

Answer 90

The most common location for conjoined roots involves the L5 and S1 levels.

Question 91

Qual a outra forma de anomalias de raízes lombares?

Answer 91

A second type of anomaly that may be as common as conjoined roots is a furcal nerve root; this refers to a bifurcation of a single nerve root. Often furcal roots are bilateral and can occur at multiple levels.

Question 92

Como evoluem os pacientes com anomalias de raízes evoluem pós operatoriamente quando comparados como pacientes sem anomalias?

Answer 92

Surgical outcomes in patients with conjoined roots tend to be significantly worse than in the general population.

Question 93

Quais são os princípios de tratamento das lesões durais?

Answer 93

Eismont, Wiesel, and Rothman suggested ive basic principles in the repair of these leaks: 1. The operative field must be unobstructed, dry, and well exposed. 2. Dural suture of a 4­0 or 6­0 gauge with a tapered or reverse cutting needle is used in a simple or a running locking stitch. If the leak is large or inaccessible, a free fat grat or fascial graft can be sutured to the dura. Fibrin glue applied to the repair also is helpful but used alone does not seal a significant leak. 3. All repairs should be tested by using the reverse Tren­delenburg position and Valsalva maneuvers. 4. Paraspinous muscles and overlying fascia should be closed in two layers with nonabsorbable suture used in a watertight fashion. Drains should not be used. 5. Bed rest in the supine position should be maintained for 4 to 7 days after the repair of lumbar dural defects. A lumbar drain should be placed if the integrity of the closure is questionable.

Question 94

Quando suspeitar de lesão da dura-máter?

Answer 94

The development of headaches on standing and a stormy postoperative period should alert one to the possibility of an undetected CSF leak. This can be confirmed by MRI.

Question 95

O que os estudos mais recentes concluem sobre a dissectomia simples e aquela associada à artrodese?

Answer 95

More recent data compar­ing disc excision alone with the combination of disc excision and fusion indicate that there is little, if any, advantage to the addition of a spinal fusion to the treatment of simple disc herniation.

Question 96

Como é definido a dor do desarranjo interno do disco?

Answer 96

Current understanding of IDD defines this as a patho­logical condition resulting in axial spine pain with no or minimal deformation of spinal alignment or disc contour.

Question 97

Quais são as características clínicas do desarranjo interno do disco?

Answer 97

Patients usually are relatively young, in the third to sixth decades of life. Pain usually is chronic with symptoms present for several years, although the pain may have become constant or very frequent only in the previous several months. The pain is axial primarily, often with buttock and posterior thigh (scleroto­mal) pain. Pain distal to the knee indicates either diferent or coexistent pathology. Positions and activities that increase intradiscal pressure, such as sitting or flexion, should exacer­bate the symptoms. Likewise, recumbency, especially in the fetal position, often decreases the pain.

Question 98

Em relação aos sinais de Waddell, quantos devem estar presentes para excluir IDD?

Answer 98

Also, examination for Waddell signs should be included, and if three or more are present, an alternative diagnosis is more likely.

Question 99

Como tratar IDD?

Answer 99

Most patients can be treated without operative intervention, especially if they are educated as to the nature of the process causing their pain, specifically that it is not relentlessly pro­gressive generally, and that continued pain does not equate with progressive deterioration or disability. Often this understanding and instruction on moderate activity modification, aerobic conditioning such as walking, and core muscle strengthening allow these patients to manage their symptoms long­term without undue worry or resource consumption.

Question 100

O que deve ser discutido com o paciente que cogita o tratamento cirurgico para IDD?

Answer 100

Before proceeding with any operative treatment, the patient should be informed that surgery leads to improvement in only 65%, leaving about 35% no better or possibly worse with respect to axial spine pain.

Question 101

Quais são as causas mais comuns de coccidínea?

Answer 101

The most common causes of coccydynia that we have observed in our practice are a single direct axial trauma, such as falling directly on the coccyx, and a subtle form of cumula­tive trauma that occurs due to long periods of sitting awkwardly.

Question 102

Como o IMC ajuda na coccidínea?

Answer 102

Obese patients have mainly posterior subluxation, normal­weight patients have mainly a hypermobile or radiographically normal coccyx, and thin patients have mainly anterior subluxation and spicules.

Question 103

Como tratar a coccidínea?

Answer 103

Nonsurgical methods such as NSAIDs and use of a donut cushion remain the standard initial treatment for coc­cydynia and are successful in approximately 90% of patients. When these methods fail to relieve pain, we have had success in reducing or eliminating coccygeal pain with the injectionof a local anesthetic and corticosteroids under fluoroscopic guidance. Although there is no clear consensus in the literature regarding the exact site of injection, we generally target the distal third of the coccyx. Excision of the mobile segment or total coccygectomy may be indicated for patients in whom conservative manage­ment fails, especially those with radiographic evidence of hypermobility or subluxation; success rates ranging from 60% to 91% have been reported in this group of patients. Out­ comes of surgery are not as good in patients with normal coccygeal mobility.

Question 104

Como está organizado o ânulo fibroso?

Answer 104

The anulus has a lamellar structure with inter­connections between adjacent layers of collagen fibrils.

Question 105

Taxa de recorrência de hérnia de disco?

Answer 105

18%